SATHI – Society for Administration of Telemedicine and Health Informatics – is a registered society formed by professionals belonging to various related disciplines such as medicine, information and communication technology, community development and public health with the objectives to enhance the access to quality and timely health care services to the most needy people irrespective of the location of their living and availability of the services through telemedicine. It aims at bringing technology to the benefit of the rural poor.

SATHI is a Resource Organization for

• Developing Software

• Training of personnel

• Field Testing

• Project management

• Disaster Relief

• Standardization

SATHI is actively involved in the promotion of responsible and proper usage of Information Technology in the Healthcare field whereby we believe that it can help the respective Healthcare workers and Medical Professionals in providing better care to the entire population without the constraints of Time and Distance.

We provide consultancy services in the fields of Telemedicine and Healthcare Informatics. Our members contribute to the projects on a voluntary basis whereby the organization tries to reimburse the actual costs incurred in managing the project. The idea of such varied professionals joining together was mooted in the realization that, at least in India, current practices and efforts in promoting Telehealth and related services had not been very successful. We felt that adoption of such technology, while showing great promise, was providing less than desired outcomes. Important related aspects to this technology such as change management and capacity building etc. were lacking and probably a different approach was required.

Some of our members have been actively helping the Ministry of Health and Family welfare as well as the Ministry of Rural Development in India as advisers and consultants towards its vision towards promoting Telehealth. Our website is www.sathi.org

The Technology

The use of telecommunications technology to provide, enhance, or expedite health care services, as by accessing off-site databases, linking clinics or physicians' offices to central hospitals, or transmitting x-rays or other diagnostic images for examination at another site.

E health however is a much more encompassing term which has been defined by WHO as :

“The delivery of healthcare services, where distance is a critical factor, by all healthcare professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of healthcare providers, all in the interests of advancing the health of individuals and their communities ”

Telemedicine was initially conceived to provide healthcare to space travelers, thereafter extending health care facilities for the geographically hard-to-reach and the undeserved. With time, Telemedicine is becoming more widespread, less costly, and new applications are emerging. Over the last decade the technology has moved from expensive room-sized systems to the desktop personal computer, now extending to the Internet as well.

India, which has a large population (1029 Million in 2001) has vastly varied terrains from Deserts, Coastal regions, Tropical Jungles, Islands and Mountains . Roads and physical reach are a problem in many areas. 72,2% of our population is rural who are supplied by less than 30% of medical professionals. Worse if one is searching for specialized medical care the Ratio is less than 4% in Rural areas. While healthcare is the responsibility of the state, the actual provision by the state is less than 30% of the needs. The reasons for these are varied but a large extent are related to the lack of actual facilities even when promised e.g. doctors may not be present or may refuse to take care stating that it is beyond his scope.

Most doctors are not willing to work in Rural areas as there is a lack of adequate facilities, not only for them to satisfactorily practice to the level of training imparted to them. Also general facilities like good schools for their children or proper social and entertainment facilities for them to maintain the standard living which they are used too, are lacking.

On an average, 50 - 60% of healthcare needs are met by simple consultations and following general health practices or taking medicines. While actual Healthcare expenditure in India constitutes is 5.2% of the GDP (compared with 2.7% in China) it is widely believed that can go upto 15% of the budget of most families. In rural areas, much of the expenditure is wasted on the transportation to the nearest healthcare facility. Though never publicized, we have been told that China has been doing tele-consultations since a long time mostly through telephone using experts in the cities and a wide network of less qualified barefoot doctors present in the community .

Setting the stage

Telemedicine is a generic term but comes in various streams -viz

Between patient and doctor (I.e. A direct virtual consultation or through Email/telephone )

Between a general Practitioner (or untrained village health practitioner or nurse as in our setting) and an expert / Specialist

Two main forms of Teleconsultations - Store and forward where data is transferred and reviewed in an asynchronous manner and Realtime where a synchronous audiovideo transfer as well as video conferencing takes place. Store and forward is simpler and easierr to implement with noting more than a basic EMR software. realtime on the other hand requires sophisticated equipment like Video conferencing equipemtn, telestethoscopes, tele ophthalmoscopes, etc and is also demainding on bandwidth. Special efforts to do the interaction like a time table etc need to be inplace.

The worldwide response to the 24 th December 2004 Tsunami disaster resulted in a massive outpouring of personnel, materials and funds, Healthcare was felt as a primary need for the survivors. SATHI offered its services stating that advances in Information Technology could provide data collection services as well as help improve the health status in a sustainable manner. We received support from the OXFAM TRUST India, the Indian Branch of OXFAM International wherein the SATHI would be providing consultancy to manage health care in the relief centres run by the NGO and its' sister organizations. It was to be an attempt to showcase the use of Information Technology in Healthcare after Disasters

After any natural or man made disaster, supplies, food etc can be moved to the affected area, but disease and healthcare needs require specialized care which in most cases mean a reverse transfer. Telemedicine has been found an effective method of helping the healthcare aspects of disasters . It can provide the specialists virtually to the affected area(s) overcoming time and geographical barriers. However, most studies in Telemedicine in general and specifically in disasters have concentrated on the technology rather than the people. We believe that shifting from a normal physical healthcare provision to a virtual availability is a significant change. This requires following of Change Management principles and the key to our approach to this project.

Schiesser defines Change Management as "a process to control and coordinate all changes to an IT production environment.

All documentation and procedures associated with the running, support and maintenance of live systems.

In a sense, capacity building of the persons running the systems is part of the change management and we are glad to be part of this effort which is now detailed herein.

The method we followed - We shall be providing training for both forms of telemedicine .the bigger component being Store and Forward technology,

In this, all medical records are stored electronically in a local database. On need for opinion, patients’ record with all images and reports are transmitted. The Specialists’ site receives and stores records. The specialist views these records and provide an opinion through E Mail, telephone or Fax

This other component in our training schedule is Real Time - whereby Speech and Eye contact for Patient provided online at the appointed time and reports are reviewed and some questions are asked for clarification or even a possible Clinical examination also done. This can be in the form of skin lesions through a digital camera or direct through the VC camera, hearing heart sounds etc through a digital stethoscope.

The doctor may directly ask the patient to do some tasks as explained by the specialist. or ask for further tests.

After that the Patient maybe provided a prescription online.

Referring doctor or the patient is then informed on what to do or Online mental health support only requires videoconferencing.

Sometimes the patient may be asked to come to for Procedure

Appointment is given and problems and means of transfer explained

In emergency situation, preparations are made for receiving the patient etc with Operation Theatre is made ready .

Learning Objectives & proposed curriculum

Learning Objectives

To be able to operate telemedicine system located at telecentre

To be able to plan and organize Telemedicine Consultation Sessions

To enhance people related skills such as communications with village people as well as with consulting doctor

Gain basic knowledge of community health emergencies for early reporting

To be able to maintain accounts related to use of telemedicine system

Proposed curriculum

1. Introduction to Telemedicine

What is Telemedicine

Evolution of telemedicine

Advantages and disadvantages of telemedicine

Future of telemedicine

2. Operating Telemedicine System

What is telemedicine system

Hardware & Software and accessories

Connectivity

How to operate telemedicine system

Do’s and Don’ts

Troubleshooting

3. Planning and organization of Telemedicine Consultation Session

What is Telemedicine Session

Pre-requisites for TMC

Fixed Day Strategy

Planning sessions and preparing service schedule

EMR

Individual and Group Session

Online and offline consultation

Facilitating Telemedicine Consultation Session

Counselling patients

4. Communicating with village people and doctor

5. Community Health

Basics or Public Health

Statistics

Public Health Records

Data collection and analysis

6. Maintenance of Accounts

Transforming current training modules

Our experiences of applications of application of ICT through village based telemedicine centre are mainly in two kinds of situations as follows:

In this situation a training module for Community Health Volunteer was prepared. It focussed on the basic healthcare at site, counseling, community organization, and facilitating telemedicine consultation with specialist in Chennai. Major part of the contents pertained to health intervention at site (the temporary shelter put up near their village which got affected due to tsunami). Rest pertained to introduction to telemedicine, communicating with people, organizing telemedicine consultation session etc. Management of patient (including drug therapy) and follow-up was learnt online during the TCS from the specialists at Chennai. Since the services made available were need based they were mostly for psychosocial disorders. Since linkages with the nearest health sub-centre were provided basic knowledge about services such at immunization ad ORT was provided.

Repackaging will essentially involve preparation of interactive programme which could be used as self learning material supported by self assessment tools. Generalization of some of the processes on telemedicine consultations will be required since earlier we were concerned about a few specific centres only and their staff needed to be trained.

b) Providing healthcare services to remotely located village community from major city (state capital) hospital.

In this situation most of the training was conducted on site and hands-on. The sites were in rural and semi-urban areas of Madhya Pradesh. The telemedicine software was used for creating dummy patients and practice sessions were organized. This was followed by actual live telemedicine consultation sessions with Specialist centre at Bhopal. Operational Manual of the telemedicine software used was the resource material. A simple instructions booklet with few illustrations was developed in local language for the telemedicine centre manager. The Doctors at the centre were also trained in operating telemedicine system and filling the data pertaining to patients.

Repackaging of the training module will be done by standardizing the essential operating processes, working out interactive learning programme and providing this on CD. Care will be taken to include only essential processes. Similarly the standard curriculum for hands-on practice and continuing educational sessions will be worked out. These will be achieved mainly by editing existing modules and manuals.

Joyful Learning

Methodology would be experiential participatory learning. It will be made more interactive using the same software and connectivity in the telemedicine system to be used. While formal classroom training will be organized at the central place in small batches of 25 -30 persons, it will be followed up with continuing education, on and offline through the telemedicine system itself or through internet. The training will be of a shorter duration say about 7-10 days (could be shortened into 5 days) and continuing education would be spread over three months in weekly sessions. The central training will be classroom based however it will be participatory, interactive, and full of practical exercises and games. The continuing education will be done through established telemedicine centres. Initially till such centres are established and functional, it could be done at any place such as Panchayat Bhavan or Common Service Centre or School.

A help module will be incorporated in the telemedicine software. Apart from this a separate electronic module will be prepared and provided on a CD to each trainee. This soft module will include animated illustrations, games and demonstration of all the key processes involved in operating the telemedicine system, organizing telemedicine consultation sessions (TCS), managing the telemedicine centre and interacting with the patients or the community at large. These modules will be very flexible and user friendly. The format will mostly be audiovisual. It will provide control with the user for adjusting the pace for learning. The online continuing education will focus on telemedicine consultations. The continuing education / briefing sessions for the telemedicine center managers would precede these sessions. Thus it will be a on the job training. However for those who are not in the job alternative arrangement will be made in the form of web based programme for continuing education or training sessions facilitated at demonstration centres temporarily set up at Panchayat Bhavan, CSC or School.

All training sessions will be related to real life. The actual patients or health service seeker in remote area in process of consultations will be the “learning materials” for the telemedicine managers. While all of these will be live, there will be provision of capturing the consultation process on video and reusing the same for greater discussions or analysis.

The telemedicine centers network and their linkages with the central places namely the specialist end and HUMACLIN / SATHI’s resource center will enable all the trainees learning on site or in a distance education programme to interact with each other with ease.

The telemedicine centre managers (operators) will be trained to meet the following learning objectives. The methodology will be participatory and based on practicals (hands-on).

The Telemedicine System comprises of the telemedicine hardware and software both at user and service provider ends connected with each other. Typically the user end will be the telecentre while the service provider end will be with distant medical doctor/expert/specialist. The telecentre manager will be the facilitator for consultation process between these two ends. Besides this basic function, we hope to use the centre as a source of health and population based data. Recording and storing of this data shall be an inbuilt function of the installed software

It is necessary that telemedicine centre manager can operate the telemedicine system. It is expected that the person has basic knowledge of computer. and working with data.

Some medical knowledge or at least the understanding of medical terms will also be helpful. We recommend that the location of the centre of the centre be adjunct to or in the premises of the healthcare worker, be it the Registered medical practitioner (RMP) or the Village Health Nurse (VHN)

Telemedicine system may include some accessories such as medical bio-grade scanner. (if required , to keep costs low – this may be replaced by a digital camera (5 – 7 Megapixels) mounted on a stand and used as a digital image generator and electronic pen and pad ((See Appendix I for a complete list of required and recommended equipment along with the specifics of training on these equipment). The training will focus on use telemedicine software which has following components .

Video-conferencing - to make it easier for all, we have installed a very basic video phone

Patient Data Module including the history, symptoms ( complaints), and other investigations records if any

Attachments to Patient basic ‘case sheet’ such as X-ray, ECG, Scan, Angiography etc which could be in digital form or scanned.

The video-conferencing facility built-in with the telemedicine software will also be used for online education/training of the telemedicine centre manager as described above, the telemedicine consultation can be done online (Realtime) or offline (Store and Forward). In the former mode the manager will facilitate interaction between doctor and patient and in latter mode s/he will transfer the patient data to doctor. Basic operations for facilitating Telemedicine Consultation with doctor ( at other end) will include the following

Opening the telemedicine software. This shall remain open at all times while the clinic is running and data entered for all patients as mentioned above.

Accessing the Electronic Medical Record (EMR) of the patient - the same is now viewed to make sure there are no gaps, errors or spelling mistakes. The same is now transferred to the expert end through an Email or request sent to the server (in case the data is stored on a central server) to set up an appointment with the particualr specialist for the patient on hand and also allow hm access to the rrecords - even better to send a copy of the record to the expert end by EMail as in attachment in arecognizble format like pdf (portable document format)

Starting the video-conferencing between two ends - this shall be at an appointed time or if required, a message sent by Mobile phone or SMS that an emergency exists and the expert is requested to start a session urgently.

A somewhat similar schedule is required at the expert end with minor differences as outlined : -

The sessions will be either following a regular time table say 3 -4 PM on Tuesday afternoon where the doctor should be in his seat between next to his PC as well as video conferencing equipment. data of the patient in the form of history, examination findings and reports shall be available in a soft or hard copy. The same needs to be revewed before the actual teleconsultation starts.

During the didactic training the telemedicine centre managers will be familiarized with the telemedicine system and its operations. The practical hand-on training will also be imparted. For this purpose actual cases (patients) will be used or dummy patients (and their records) can be used.

Telemedicine Consultation Sessions (TCS) will be a planned session between a number of patients and doctor(s). A fixed day fixed time schedule (e.g. Every Tuesday between 1400- 1700 Hrs) will be followed. This is the virtual OPD ( outpatient department like in any hospital). Provision for emergency contact will be present.

For the current project, we shall be arranging for the specialist to reach teh telecentre at the appointed time at the expert time while teh patient with all his reports shall be present at the peripheral end.

The training module will include planning exercises as well as real life situation at telecentre. This could be done on one-to-one basis or with a group. Certain cases may demand confidentiality and privacy while most of health education or counselling sessions could be done in group. Indications for such types will be illustrated in the module. Theoretical part covered through training session will include definition of TCS, processes involved and records management. The practical will include mock sessions or actual sessions. It will be a fun as online support and guidance will be simultaneously available from doctor(s) also providing direct supervision. Every TCS in future will be a learning opportunity for the telemedicine centre manager.

Objective 3: To enhance people related skills such as communications with village people as well as with consulting doctor

The training module will emphasize on the communications skills. Games and exercises will be the main methods for enhancing communications skills. Telemedicine Consultations are practical exposures and learning opportunities for developing communications skills. Telemedicine Consultation Sessions will be followed by briefing sessions where the TCS will be analyzed by the Trainer explaining and interpreting principles of communications.

Objective 4: To gain basic knowledge of community health emergencies for early reporting

Telemedicine System provides lively contestant linkage between peripheral end (at village/ small town level) and doctor at higher level (Block, district, state etc). Apart from individual medical consultations, telecentre could be a surveillance centre (the eyes and years of health system in region). Unusual incidence of any disease, particularly notifiable disease, could be noticed by telemedicine centre manager. Some warning systems may be avaialbel in the software itself but if there is some knowledge of data mining and searching by the telecentre manager, they will be able to notice such happenings as not all occurrences can possibly be provisioned for.

Outbreak of epidemic can also be noticed and telecentre could be a good platform for response activities. The role of telemedicine centre manager in this respect can be simplified and basic of epidemiology will be included in curriculum. This role can in future be expanded to play a role in disaster management. The distinct advantage of telecentre will be early detection of silent epidemics such as nutrition deficiency disorders, psycho-social disorders etc.

The telecentre also has ot function as a health centre in which basic care provision will be given in the absence of trained personnel. If any surgical emergency occurs, the local healthcare worker as well as he telemdicine technician should be able to provide some care. Some methods for such care and provision should be searchable from teh intternet e.g.The link http://www.who.int/surgery/publications/imeesc/en/index.html provides basic surgical help as welll as deliveries

Objective 5: To enable telemedicine centre manager to maintain accounts related to use of telemedicine system

The telemedicine centre needs to be self sustaining. User charges from the patients seeking medical consultations through telemedicine system will have to be collected. Apart from payment of doctors’ fees, the maintenance of the system will be handled by the manager. Basic accounts keeping specifically related to telemedicine centre operations will be part of the curriculum. This will be dealt with through practical exercises. In later stages of development of Telemedicine Systems Network this component can be integrated with the telemedicine software.

Conceptual and theoretical framework

The number of telecentres in India is growing rapidly both in public and private sectors. While at some places they are providing exclusive service such as medical consultation, most of them are meant for a bundle of many services from multiple sectors. Common Service Centres (CSC) scheme of Government of India plans to establish 100,000 CSCs in 600,000 villages. The CSC is envisioned as front-end delivery point for Government, private and social sector services to rural citizens of India . Similarly in private sector a number of companies have started similar Centres for bundle of services. Healthcare services component, though part of such bundle is mostly missing. The main reason for this is the lack of capacity to manage such telecentres as telemedicine centres. There is a need to train such managers specifically in operationalization of telemedicine system through telecentres. Literate rural youth can be trained as Telemedicine Centre Manager can be trained to be telemedicine centre managers. Thus employment opportunities could be provided to them. On the other hand availability of such trained manpower will act as propelling force for opeartionalization of telecentres as telemedicine centres. In absence of trained telemedicine centre managers, the telecentres will simply not function as telemedicine centres. Access to health services is a major issue in rural India . Information and Communications Technology can address this issue. Access to health services through telecentres will also give boost to utilization of other services available there since health is much felt need. This will contribute to making telecentre self-sustainable and economically viable.

Thus there is urgent need of building the capacity in form of raising a cadre of Telemedicine Centre Managers. This could be done by either way: a) by training persons already working as telecentre managers in telemedicine business operations and b) by training rural youth.

Though there are many initiatives to set up telecentres, at present the opportunities to get training as telemedicine centre manager are virtually non existent. The huge gap can not be filled by isolated initiatives at limited scale. Therefore we wish to develop a standard training module and methodological approach for imparting such training. Thus the training approach, support materials and methods will constitute to be the comprehensive tool kit for undertaking training activity and carrying it out effectively.

There are and will be various software of telemedicine in the market and in use. However our training module will be relevant for all of them since it will be based on the fundamental processes involved in telemedicine consultation.

User participation

The current project is being piloted in Orissa (see Annexxure II)

In this project we shall be developing the training module and methodology. This will be done by building upon basic training modules that we had developed in our previous projects namely “Healing Touch” telemedicine project for Tsunami affected population and ATMS Project for private sector in MP. Users – the telemedicine centre facilitators- participated in development of the training modules. In fact the training modules were developed on site based on the needs of identified facilitators because it was emergency response to Tsunami and we had to get telemedicine system working at the earliest. Subsequently the training modules were organized systematically. Now this training module will be reviewed and revised with users participation.

Genderconsiderations

Gender consideration is not crucial in this project as far as process of development of training module is concerned. However as regards contents of the training are concerned gender sensitization of the Telemedicine Centre Managers (the trainees) will be built in. This will be addressed by explaining gender issues related to healthcare services utilization through games and examples or case studies.

Annexure 1

Matrix of Learning objectives and methodology of training modules

Items highlighted in (pink) by S B Gogia,(Blue) by Dr Surwade ,(Yellow) Jaishree to help arrange / local recording Others free for the asking

Different Types of disasters/ natural calamities and their implications on the health of the people

Lecture

A-V presentations

Importance of disaster preparedness

Interactive sessions

Role of Telemedicine Centre in Disaster management and health response

Annexxure II

Details of our current project in Orissa

In this project, an expert center in Bhubhaneshwar (at our own office) is being linked to Peripheral centres at 3 places in the districts of Nayagarh and Boudh. The software and Video conferencing equipment is in place at the expert end as well as at these three centres.Preliminary training has been provided and actual trials are awaiting a build up of the proper physical as well as social 3 networking infrastructure. There are 2 -3 more where currently only the software is installed by the trained users themselves.

The following procedures gave been followed and progress is continuing:-

Guide to electronic health care/medical libraries on the internet Guide on how to obtain access to a variety of full-text health and medical journals, books, and other resources. Key featured libraries include HINARI, Highwire Press, BioMed Central, Directory of Open Acess Journals, and Bioline International. Available in English and Russian. Eurasia Health Knowledge Network. www.eurasiahealth.org/eng/health/resources/81628

Both resources are included in ProCor's Resources section ( www.procor.org/resources ). ProCor is a global communication network promoting cardiovascular health in developing countries and other low-resource settings. Resources are updated on the website and sent out to the email network on a weekly basis. You are also welcome to use the 'Search by Topic' page ( www.procor.org/search ) to search for resources related to 'training of health personnel' and 'access to information.'

1. http://www.thefreedictionary.com/telemedicine

2. The World Factbook 2001, CIA Publication, Office of Public Affairs.

3. Asia And The Pacific In Figures 2000, Statistics Division, United Nations Economic and Social Commission for Asia and the Pacific (ESCAP)

1 The current video conferencing device is a video phone - as easy to use as any mobile or landline phone. One just dials the requisite number (can be stored in the local phone book which is also a visual component tof the phone itself) and one can view the other party directly. Your own image will be prsent ina Picture in picture mode so that one can adjust the view for shadows, hiding clarity etc. by turning the swivel camera.

2 We believe that all patients data should be recorded and stored locally so that such a method becomes routinized. Transfer for a tele-consultation then entails no extra effort and will be treated and managed as routine activity.

3 Social networking is important as the various stakeholders i.e. The expert doctors and the healthcare workers in teh periphery should be part of a team so that they understand the capabilities of each and every one.